Provider Demographics
NPI:1154105005
Name:BETHUNE-ODOM, CYNTHIA R
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:BETHUNE-ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9230 COUNT FLEET DR APT 305
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-6211
Mailing Address - Country:US
Mailing Address - Phone:727-729-0594
Mailing Address - Fax:
Practice Address - Street 1:9230 COUNT FLEET DR APT 305
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-6211
Practice Address - Country:US
Practice Address - Phone:727-729-0594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program